Journal of Clinical Trials
Open Access

Comparative Efficacy of Gingival Massage of Aloe-Vera Gel and Sidr Honey on Gingival Health: A Randomized Clinical Trial

Author info »

Abbreviations

SPSS: Statistical Package for the Social Sciences; BOP: Bleeding on Probing; PI: Plaque Index; GI: Gingival index; SRD: Scaling and Root Debridement

Background

The oral cavity fosters a complex microbiota comprised of more than 700 different bacterial species which resides in dental plaque [1,2]. Dysbiosis of microbiota is the primary key factor that leads to gingival inflammation. Plaque-induced gingivitis is an inflammatory response of the gingival tissues resulting from bacterial plaque accumulation located at and below the gingival margin [3]. Epidemiologic data have shown, plaque-induced gingivitis to be prevalent at all ages in dentate populations [4], and this disease is considered the most common form of periodontal disease, creating a complex dynamic between the dental plaque biofilm and the host's immune inflammatory response [1,4,5]. Patients may notice symptoms that include bleeding with tooth brushing, blood in saliva, gingival swelling and redness, and halitosis in the case of established forms [5]. The common clinical signs of plaque-induced gingivitis include erythema, edema, bleeding, tenderness, and enlargement [3], however, gingivitis may not cause tooth loss but primary prevention against Periodontitis is to subside gingivitis [1,4]. Hence treatment and maintenance is necessary for gingivitis. The primary goal for treatment of gingivitis includes removing of microbial agents and risk factors to prevent progression of disease and establishing a maintained gingival tissue health [6]. Mechanical method for plaque control is tooth brushing [6], but in gingivitis, there is a need for professional dental care which includes non-surgical periodontal therapy [7]. This therapy is aimed to abolish bacterial plaque and calculus from supra gingival and sub gingival areas and to resolve the gingival health. After NSPT a number of topical antiseptics, anti-inflammatory and antibiotics agents are available which promotes healing of gingival tissues and are beneficial in treatment of gingivitis [8-10].

Gingival massage is also a method to treat gingival tissues. Gingival massage works by stimulating the blood circulation, provoking active hyperemia, and thus increasing tissue respiration and transport of detritus products [11]. Another effect of massaging gingiva is to churn out dense connective tissue, which in turn increases keratinization of gingival tissues. In surmising, the advantages of massage are: A healthier gingival circulation, periodontal stimulation, abolition of food debris, dwindling bacteria and mucinous plaques, and the keratinization of epithelium encircling the tooth which firms and narrows the orifice to the pocket [12,13]. A study compared gingival massage of three different oils (sesame, coconut, and olive oil) and chlorhexidine gel in reducing oral microorganisms, they concluded significant reduction of microorganisms, plaque scores and gingival scores, and however no significant difference was found among the four groups [14].

In recent years a lot of herbal medicine has been used in dentistry such as green tea, olive oil, turmeric, almond oil. Honey and aloe vera have been used in gingivitis, periodontitis, root canal medicament and post extraction healing sockets for their beneficial effects [15-18]. Honey has antibacterial activity and was first recognized by Ketel et al. in 1892 [19]. Natural honey is a simple, effectual, cheap and cheerful agent, which is obtainable, and it can be an affordable therapeutic agent [20]. Honey has healing properties, subsides pain, infection, inflammation and also removes malodor [21]. It is easily available with no side effects or toxicity nor any resistance reported, with all these favorable reasons honey can be used as an alternative to antimicrobial therapy [22,23].

A study compared honey, mouthwash and combination of chewing gum and mouthwash on plaque level and concluded honey group and mouthwash with chewing gum group were more effective than mouthwash group alone [24]. Molan suggested, the use of soft gelled form of honey can be applied on the gingival margin periodically to prevent gingivitis or colonization of caries causing bacteria on the gingiva [20]. Researcher’s claims that honey candies may prevent halitosis or oral bad breath, as honey is found to rapidly remove bad smell from infected wounds. Literature indicated that honey can be used in the treatment of dry socket, mouth ulcers and periodontitis. The anti-inflammatory action of honey gives the soothing effect on topical applications [25]. The antioxidants present in honey along with the anti-inflammatory action prevent the deterioration of gingival and periodontal tissues [18-20,22,23,26,27].

Aloe-vera (Alloeh) means "shiny bitter substance" and "vera" a Latin word means "genuine" [17,28]. comprise of vitamins, enzymes, minerals, amino acids and sugars. Aloe-vera gel medicinal effect in animal models, in vitro or in oral cavity has shown to have anti- inflammatory, anti-arthritic, and anti-bacterial effects [15,17,28,29]. Aloe-vera gel has shown favorable results when applied directly to the traumatized gum tissues which are caused by toothpick or dentifrice abrasives. It also helps to sooth chemical burns from aspirin and aids in healing of extraction sockets [15,17,28,30]. Due to all these beneficial effects of honey and aloe-vera gel, use of these natural products can be considered an admissible method for controlling and preventing gingival inflammation. Topical allopathic gel application may cause some side effects like altered taste sensation, dryness, itching and swelling of oral mucosa, on contrary natural pharmacons like honey and aloe-vera gel, may not cause severe side effects, but also acts as antibacterial and anti- inflammatory agent.

Taking this into account, this clinical trial was conducted to compare the effects of gingival massage efficacies of honey and aloe-vera gel as adjunct to non-surgical therapy in patients with gingivitis, for this purpose, we assessed clinical parameters which were plaque index, gingival index and bleeding on probing.

Materials and Methods

Study design and study setting

The randomized controlled clinical trial was conducted in department of Periodontology at Dow university of Health Sciences, Karachi, Pakistan. This clinical trial was approved by the Institutional Review Board of Dow University of Health Sciences (Ref: IRB-1272/DUHS/Approval/2019/55). The research protocol was registered with the Protocol Registration and Results System at ClinicalTrials.gov, under the protocol ID NCT05231096, on February 9, 2022 in accordance with the CONSORT statement of the updated guidelines.

Characteristics of participants

Written consent was obtained from all participants to participate in the four-week clinical trial. Study included participants without systemic disease, both male and female, 20-60 years of age with plaque induced gingivitis, presence of plaque, signs of gingival inflammation and bleeding on probing ≥ 20% sites, pocket depths of 1-3 mm and no clinical attachment loss. Minimum of 5 teeth in each quadrant excluding 3rd molars. Individuals who smoke, any addiction of areca nuts, gutka, paan or alcohol, any systemic diseases like diabetes mellitus, cardiovascular, endocrine as they may affect the outcome of research, women with pregnancy/ lactation, and individuals with any known allergy from aloe-vera or honey, systemic or topical use of antibiotic in past 6 months were excluded from the study. In this clinical trial, 105 patients diagnosed with plaque induced gingivitis were recruited. The enrollment, allocation of patients and intervention given to the teeth is given in Figure 1.

Figure 1: Flow diagram for enrollment, allocation of patients and intervention.

Sample size calculation

Total of 105 patients were calculated (35 in each group) by using PASS version 11 software, paired sample t-test with 95% confidence interval and 80% power of test. Difference of plaque index at base line versus after 1 month mean 20.02 ± 68.16, calculated sample size was 93, which was increased to 105 [29].

Description of interventions

Aloe-vera gel production: Aloe vera gel used in this study was, 98% aloe vera gel concentration mixed with 2% normal saline. Preparation of aloe-vera gel was from ripen leaves of aloe-vera [29]. Aloe vera leaves were washed thoroughly under water, then cut from the center, and the seeping gel was collected in sterile container, was stored at 4°C, until the time of application. In our research this pure Aloe vera gel (Figure 2), was extracted by The Pakistan Council of Scientific and Industrial Research (PCSIR) laboratory.

Figure 2: The container contains Aloe-vera gel.

Honey collection: Sidr (Beri) honey (Figure 3), was used in this study. Honey was thick, raw and cold. It extracted from Sidr trees. It was smooth, viscous and medium to dark amber in color.

Figure 3: The bottle contains Sidr (Beri)honey.

Data collection procedure

Participants, signing the consent form were enrolled in the study. All the enrolled participants went through a detailed history which included medical health, systemic illness, regular medications, hospitalizations, any known allergies, dental checkups, any bad oral habit and routine oral hygiene practice. Any entrant having any allergy from honey or aloe-vera gel or anyone falling in our exclusion criteria were not selected in our research. All those who fulfilled our criteria were clinically examined and all the clinical parameters were recorded by the principal investigator at the baseline, i.e. gingival index, plaque index and bleeding on probing. Bleeding on probing (Figure 4), was checked on the buccal and lingual sulcus of tooth, after inserting the probe and wait of 30 seconds, if bleeding occurred, bleeding on probing was considered as 1 and labeled as positive Bleeding on Probing (BOP), and if there was no bleeding, it was considered as 0 and labeled as no bleeding on probing. Percentage of BOP was recorded by dividing positive bleeding sites by total number of sites present in each patient multiplied by 100. Gingival index (Loe and Silness, 1963) was recorded as score 0: Normal gingiva, 1: Mild inflammation on gingiva, 2: Moderate inflammation on gingiva and 3: Severe inflammation on gingiva. Plaque index (Loe and Silness, 1964) was recorded as score 0: No plaque, 1: plaque film on free gingival margin, 2: Moderate plaque on gingival margin; can be seen by the naked eye, 3: Abundance of soft matter in gingival pocket. After recording all the clinical parameters, principal investigator performed non- surgical periodontal therapy (scaling and root debridement) by using ultrasonic scalers in single visit. Following scaling and root debridement (Figure 5), the participants of all the three groups were given detailed oral hygiene instructions with demonstration of proper brushing technique i.e. Modified Bass technique. After that, all the participants were provided with a regular cleaning kit which consisted of fluoride toothpaste (Colgate^® Cavity Protection Toothpaste) and toothbrush (Colgate^w Classic Clean Toothbrush). Moreover, all enrolled patients in Group A and B were minutely demonstrated by principal investigator for gingival massage. Intra- examiner reliability was checked to ensure calibration between examiners. For this purpose, both examiners recorded clinical parameters of 50 subjects with gingivitis who were not involved in our study and reliability came out to be 88%.

Figure 4: Bleeding on probing. This is clinical picture was taken at the time of recruitment after SRD. BOP can be noted on upper arch.

Figure 5: Ultra-sonic scaling. This is a clinical picture of gingivitis patient taken during ultra-sonic scaling.

Random allocation of intervention

A total of 105 participants were divided in to three groups and were named as Group A: Gingival massage with Aloe-vera gel, (Figure 6), Group B: Gingival massage with Sidr honey (Figures 7a and 7b), and group C: Control group. Interventions were randomly allocated. For this purpose, entrants were asked to pick one sealed opaque envelope in which random allocation of the interventions were mentioned. All the participants who were in Group A and B were not blinded and trained for gingival massage by principal investigator. All the participants were guided to rub aloe-vera gel or sidr honey on the skin of wrist first to recheck any allergy. At last participants were trained for application of the material gently on the gingiva and the gingival sulcus of all the teeth. To perform gingival massage patients used the index finger of their dominant hand, applied the material at the bottom of their gums with slight pressure, then moved the finger in a slow and circular motion/ rubbing action for 1 to 3 minutes. After performing the massage patients were not allowed to rinse with water or any other fluids for 30 minutes for further retaining the material on the gingiva and in the gingival sulcus thereby preventing washing out of the material. All the patients were instructed to perform gingival massage with aloe-vera gel and sidr honey twice a day after meals and to wait for 30 minutes after application of the interventions. All the routine oral hygiene practice which includes brushing twice a day (morning and night) was continued as usual. Patients falling in the control group were instructed to follow routine oral hygiene protocols. Telephonic communications were made weekly for encouraging the patients for gingival massage with given interventions. All the patients were recalled on 30^th day for Post-intervention assessment (Figures 8a and 8b). The baseline clinical parameters were recorded by principal investigator whereas 1-month follow-up of all clinical parameters were recorded by a trained examiner in this study. The trained examiner who was blinded from the intervention given to patients, was asked to re-assess all the clinical parameters which included gingival index, plaque index and bleeding on probing. Study Variables were included Gingival Index [GI], Plaque Index (PI), Bleeding on Probing (BOP).

Figure 6: This is a clinical picture of the study participant taken at the time of recruitment. Generalized Calculus along with gingival inflammation and redness of Interdental papilla can be seen.

Figure 7: These are the clinical picture of the participant taken at the time of recruitment. Generalized calculus with gingival inflammation can be seen on Upper and Lower arches.

Figure 8: No bleeding on probing in both arches. These are the clinical picture of same patient taken after 30 days of SRD along with gingival massage with Sidr Honey, improvement in gingival.

Statistical analysis

Data processing and analysis was done by using IBM SPSS version 21.0 software. As per appropriate distribution, Data for each tooth site was entered in Microsoft excel for pocket depth and mean score was calculated for baseline and same sites were observed for improvement after 1 month. Percentages were reported for plaque index and gingival index. Percentages were reported for bleeding on probing, cutoff of ≥ 20% and ≥ 30% was set to analyze before and after differences in bleeding on probing in all three groups. Non-parametric test like Wilcoxon signed ranked test and Mann Whitney test were applied. Wilcoxon signed ranked test was applied for pre- and post-comparison within groups for gingival index, and plaque index. Mann Whitney test was applied to analyze statistically significant differences between groups in gingival index, and plaque index. The p-value of<0.05 was considered as significant.

Ethical consideration

The present study was safe for all the patients as the study was completely non-invasive. All the participants signed a written consent form prior to inclusion. There was only topical application of natural products i-e Aloe-vera gel and Sidr Honey which have already been used in other studies and no known adverse effects and complications have been reported.

Results

A total of 105 patients were recruited in three groups’ i.e., Group A (gingival massage with Aloe-vera gel), Group B (gingival massage with Sidr Honey) and Group C (control group), and out of these three participants were loss to follow-up, one from group A and two from group C. There were 57 (56%) males and 45 (44%) females with an average age of 48 ± 8.6 years.

Comparing gingival massage effects on plaque index

In all the three groups significant reduction in plaque levels within groups were observed (Table 1). Moreover, Aloe-vera vs. honey (p-value>0.05) showed no significant changes, whereas honey vs. control (p-value<0.001) and Aloe-vera vs. control (p-value<0.001) showed statistically significant differences. (Table 2).

Table 1: Gingival massage effects on plaque index among groups.

Table 2: Gingival massage effects on plaque index.

Comparing gingival massage effects on gingival index

In group A, B and C statistically significant changes were seen with P-value<0.001 within groups. Highly significant differences were observed between group A and C (Tables 3 and 4).

Table 3: Gingival massage effects on gingival index among group.

Table 4: Gingival massage effects on gingival index.

Comparing gingival massage effects on bleeding on probing

After gingival massage with Aloe vera gel only 14.7% bleeding on probing sites were left whereas in honey group only 8.6% sites were present. In control group 36.4% sites were left when cutoff was set at ≥ 30% (Table 5).

Table 5: Gingival massage effects on bleeding on probing.

Discussion

Plaque-induced gingivitis is one of the most frequent periodontal diseases, affecting more than 90% of the population, regardless of age, sex or race [31-34]. Gingival tissues can heal after complete removal of factors i.e. plaque and calculus, and optimizing oral hygiene protocols. Till date scaling and root debridement is the most basic procedure to optimize the gingival and periodontal tissues [8,35]. However, the therapy alone does not restore all the gingival tissues and supplementary aids are used as adjuvant to scaling and root debridement [29,35]. A bundle of studies has claimed favorable effects of natural products like olive oil, almond oil, green tea, propolis, honey and aloe vera [25,29,30,36-38].

In this study we observed synergistic effects of gingival massage with two naturopaths that is aloe vera gel and sidr honey compared with control group. Our study comprises of 102 participants of gingivitis, mean age reported in our study is 48.6 ± 8.6 which is similar to a survey in United States which reported higher prevalence of gingivitis in adults with mean age as>30 years [39]. Likewise, another study which was done in Saudia reported age group to be 18 to 40 years [40], which is concordant to the current study. In this study, gingivitis was found more in males as compared to females. While some previous studies showed that more females were diagnosed with gingivitis as compared to males [4].

In present study, gingival massage effect was favorable with both interventions. However significant differences were noted in between aloe-vera gel and sidr honey. In Aloe vera gel gingival massage group, there was significant reduction of plaque index, gingival index and bleeding on probing when compared with control group. There are some studies which reported similar findings regarding use of aloe vera gel [27]. However the synergetic effects of gingival massage with aloe vera gel, has not been documented. However, a study conducted in Brazil reported no significant differences in plaque index and gingival index, between aloe vera and control group, conflicting the findings of this research [29]. An in vitro study demonstrated high antimicrobial effects of aloe vera tooth gel against streptococcus mitis, when compared with commercially available toothpaste [41]. It is noteworthy that aloe vera gel comprises a unique blend of ingredients, which are responsible for antibacterial, antiseptic, anti-oxidant and anti- inflammatory properties [30,42-44]. Furthermore it causes wound healing by proliferation of fibroblast, by initiating angiogenesis or activating macrophages, all these above mentioned properties may play key role behind diminution of gingival index, plaque index and bleeding on probing [45,46].

Regarding Sidr honey gingival massage group, highly significant differences in gingival index, plaque index and bleeding on probing were observed when compared with control group. This finding is somewhat similar to many studies conducted by using variety of honey as a topical gel, chewing gum or mouthwash [22,24,47]. However, there is a dearth of literature regarding effects of Sidr honey on gingivitis.

A study conducted in New Zealand in year 2017 reported, topical application of Manuka honey is effective in antimicrobial plaque control, and more sensitive against gram negative anaerobes, primarily causing gingivitis [18]. Likewise, research reported significant reduction in plaque levels and gingivitis when a chewable Manuka honey product was used three times a day for ten minutes. This study favors results of present study [48]. Moreover, a study done in Malaysia, reported conflicting results from present research [49]. It is worth mentioning that variations in floral honey, determines different qualities and properties, moreover potential difference in reducing inflammation and microbial load is significant among darker and unheated honey [18,50,51]. In this present study Sidr honey has both of these qualities which may be a factor which halt bleeding on probing, diminishing gingival index and maintaining low plaque level [26,51-53].

This present study aims to compare gingival massage effects of Aloe- vera gel and Sidr honey on gingivitis by assessing the differences in plaque index, gingival index and bleeding on probing. In this research outcome of both the naturopaths results in diminishing all the clinical parameters, however there were significant statistical differences between Aloe-vera gel and sidr honey. Our study reported Sidr honey is highly significant in reducing all clinical parameters than Aloe-vera gel. A randomized controlled trial conducted in year 2015 concluded effective reduction in gingival scores, when gingival massage with honey or olive oil was done for 3 weeks. Another study conducted on patients having dry socket after extraction and having mouth ulcers also reported clinical improvement after topic honey application [16,36,51].

Moreover, studies conducted by Anushri and Aetraf inferred that honey can stimulate the growth of granulated tissues and the epithelial cells, which helps in periodontal tissue repair, thus eliminates periodontal pockets. These findings support the outcome of present study [22,43]. Likewise a latest clinical study conducted in Norway in year 2015 showed notable improvement in plaque index, probing pocket depth, and gain in clinical attachment loss after the placement of aloe vera gel in the periodontal pockets in type 2 diabetes mellitus [54]. Furthermore recent studies by Kurian and sundarker have reported increased granulation tissue in healing wound after topical application of aloe vera gel which is due to production of hyaluronic acid and dermatan sulfate [15,37,55]. Literature claims favorable effects of both the naturopath but it is worthy to note that periodontal therapy itself ceases the progression of gingivitis and halts its complications [23,56-60]. That being said, if good oral hygiene is practiced and reinforced then reduced plaque accumulation significantly helps to eliminate disease progression [7,61-63]. Eventually above reported literature supports the outcome of present study which is significant differences in clinical status of gingivitis patients when gingival massage of Aloe-vera gel and Sidr honey is used as adjuvant to scaling and root debridement, thus all of them may have synergistic effects in reducing all the clinical parameters.

Recommendations

In the future, more studies are needed to evaluate the diverse effects of gingival massage and its synergistic effects when combined with any naturopath like aloe-vera gel or sidr honey, as there are few studies and inconsistent results. Different methodologies and techniques maybe used to determine various results. More rigorous studies must be conducted because of the paucity of literature on gingival massage.

Conclusion

This clinical trial showed that gingival massage with both naturopath’s aloe vera gel and sidr honey were equally significant in reducing gingivitis, by diminishing plaque index, gingival index and bleeding on probing. However, findings suggest that sidr honey gingival massage was highly effective when compared to aloe vera gel and control group. This study provides an opportunity to perform oral hygiene procedures with natural products easily at home. Therefore, gingival massage with both the naturopaths is well-to-do as an adjunct to scaling and root debridement and it can be used in dental OPD’s for the treatment of gingivitis.

Acknowledgments

I would like to acknowledge department of periodontology for facilitation in data collection.

Authors's Contributions

• FK was the principal investigator and has contributed to design, conception, data acquisition, interpretation, and drafted the manuscript.

• SAJ has contributed to conception, design, interpretation of results and critically revised the manuscript.

• WAF has contributed to data analysis, interpretation and contributed to statistical analyses.

• HP has contributed to data acquisition and Turnitin.

• SR has contributed to draft discussion and critically revised the manuscript.

• SS has contributed to draft background and data acquisition.

• MG has contributed to draft background and data acquisition

• ZRK has contributed to grammar checking and critically revised the manuscript.

All authors have conjointly given final approval and agreed to be accountable for all aspects of the work.

Funding

This clinical trial is not funded by any agencies in the public, commercial or not-for-profit sectors.

Availability of Data and Material

The datasets used and/or analyzed during the current study are available from the corresponding author on request.

Declarations

Ethics approval and consent to participate: This clinical trial was approved by the Institutional Review Board of Dow University of Health Sciences (Ref: IRB-1272/DUHS/Approval/2019/55) and was registered under the protocol ID NCT05231096, on February 9, 2022 in accordance with the CONSORT statement of the updated guidelines for reporting randomized clinical trials. Written consent was obtained from all participants to participate in the four-week clinical trial.

Consent for Publication

Not applicable.

Competing Interests

The authors declare that there is potentially no conflict of interest related to the article.

References

1. Curtis MA, Zenobia C, Darveau RP. The relationship of the oral microbiotia to periodontal health and disease. Cell Host Microbe. 2011;10(4):302-306.

   [Crossref] [Google Scholar] [PubMed]

2. Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006;94:10-21.

   [Crossref] [Google Scholar] [PubMed]

3. Murakami S, Mealey BL, Mariotti A, Chapple IL. Dental plaque–induced gingival conditions. J Clin Periodontol. 2018;45:17-27.

   [Crossref] [Google Scholar] [PubMed]

4. Ababneh KT, Abu Hwaij ZM, Khader YS. Prevalence and risk indicators of gingivitis and periodontitis in a multi-centre study in North Jordan: A cross sectional study. BMC Oral Health. 2012;12:1-8.

   [Crossref] [Google Scholar] [PubMed]

5. Hujoel PP, White BA, Garcia RI, Listgarten MA. The dentogingival epithelial surface area revisited. J Periodontal Res. 2001;36(1):48-55.

   [Crossref] [Google Scholar] [PubMed]

6. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc. 1962;65(1):26-29.

   [Crossref] [Google Scholar] [PubMed]

7. Van der Weijden GA, Hioe KP. A systematic review of the effectiveness of self‐performed mechanical plaque removal in adults with gingivitis using a manual toothbrush. J Clin Periodontol. 2005;32:214-228.

   [Crossref] [Google Scholar] [PubMed]

8. Sanz M, Teughels W, Group A of the European Workshop on Periodontology. Innovations in non‐surgical periodontal therapy: Consensus report of the sixth European workshop on periodontology. J Clin Periodontol. 2008;35:3-7.

   [Crossref] [Google Scholar] [PubMed]

9. Gingivitis PI. Treatment of plaque-induced gingivitis, chronic periodontitis, and other clinical conditions. J Periodontol. 2001;72:1790-1800.

   [Crossref] [Google Scholar] [PubMed]

10. Salvi GE, Lang NP. The effects of non-steroidal anti-inflammatory drugs (selective and non-selective) on the treatment of periodontal diseases. Curr Pharm Des. 2005;11(14):1757-1769.

    [Crossref] [Google Scholar] [PubMed]

11. Leonard HJ, Barkann L, Beube FE, Garvin MH, Giesecke M, Greenhut WM, et al. In our opinion: Is massage a valuable treatment in gingivitis and periodontitis?. J Periodontol. 1948;19(2):63-79.

    [Crossref] [Google Scholar] [PubMed]

12. Hirschfeld I. Gingival massage. J Am Dent Assoc. 1951;43(3):290-304.

    [Crossref] [Google Scholar] [PubMed]

13. Simaan C, Skach M. Clinical and histological evaluation of gingival massage in the treatment of chronic gingivitis. J Periodontol. 1966;37(5):383-390.

    [Crossref] [Google Scholar] [PubMed]

14. Singla N, Acharya S, Martena S, Singla R. Effect of oil gum massage therapy on common pathogenic oral microorganisms-A randomized controlled trial. J Indian Soc Periodontol. 2014;18(4):441-446.

    [Crossref] [Google Scholar] [PubMed]

15. Subramaniam T, Subramaniam A, Chowdhery A, Das S, Gill M. Versatility of aloe vera in dentistry-a review. IOSR J Dent Med Sci. 2014;13(10):98-102.
16. Vallianou NG, Gounari P, Skourtis A, Panagos J, Kazazis C. Honey and its anti-inflammatory, anti-bacterial and anti-oxidant properties. Gen Med. 2014;2(132):1-5.

    [Crossref] [Google Scholar]

17. Mangaiyarkarasi SP, Manigandan T, Elumalai M, Cholan PK, Kaur RP. Benefits of Aloe vera in dentistry. J Pharm Bioallied Sci. 2015;7:255-259.

    [Crossref] [Google Scholar] [PubMed]

18. Safii SH, Tompkins GR, Duncan WJ. Periodontal application of Manuka honey: Antimicrobial and demineralising effects in vitro. Int J Dent. 2017; 2017:9874535.

    [Crossref] [Google Scholar] [PubMed]

19. Ng W, Ken KW, Kumar RV, Gunasagaran H, Chandramogan V, Lee YY. In vitro screening of Malaysian honey from different floral sources for antibacterial activity on human pathogenic bacteria. Afr J Tradit Complement Altern Med. 2014;11(2):315-318.

    [Crossref] [Google Scholar] [PubMed]

20. Molan PC. The potential of honey to promote oral wellness. Gen Dent. 2001;49(6):584-589.

    [Google Scholar] [PubMed]

21. Bansal A, Ingle NA, Kaur N, Ingle E, Charania Z. Effect of gum massage therapy with honey and olive oil on common pathogenic oral micro-organisms: A randomized controlled clinical trial. J Int Oral Health. 2015;7(11):63.
22. Eteraf-Oskouei T, Najafi M: Traditional and modern uses of natural honey in human diseases: A review. Iran J Basic Med Sci. 2013;16(6):731.

    [Google Scholar] [PubMed]

23. Ahmadi–Motamayel F, Hendi SS, Alikhani MY, Khamverdi Z. Antibacterial activity of honey on cariogenic bacteria. J Dent (Tehran). 2013;10(1):10.

    [Google Scholar] [PubMed]

24. Jain A, Bhaskar DJ, Gupta D, Agali C, Gupta V, Gupta RK, et al. Comparative evaluation of honey, chlorhexidine gluconate (0.2%) and combination of xylitol and chlorhexidine mouthwash (0.2%) on the clinical level of dental plaque: A 30 days randomized control trial. Perspect Clin Res. 2015;6(1):53-57.

    [Crossref] [Google Scholar] [PubMed]

25. Samarghandian S, Farkhondeh T, Samini F. Honey and health: A review of recent clinical research. Pharmacognosy Res. 2017;9(2):121.

    [Crossref] [Google Scholar] [PubMed]

26. Othman AS. Antibacterial activity of bee and Yemeni sidr honey against some pathogenic bacterial species. Int J Curr Microbiol Appl Sci. 2014;3(10):1015-1025.
27. Shaikh S, Kumar SM. Beneficial effects of specific natural substances on oral health. Saudi Med J. 2017;38(12):1181-1189.

    [Crossref] [Google Scholar] [PubMed]

28. Vogler BK, Ernst E. Aloe vera: A systematic review of its clinical effectiveness. Br J Gen Pract. 1999;49(447):823-828.

    [Google Scholar] [PubMed]

29. Moghaddam AA, Radafshar G, Jahandideh Y, Kakaei N. Clinical evaluation of effects of local application of aloe vera gel as an adjunct to scaling and root planning in patients with chronic periodontitis. J Dent. 2017;18(3):165.

    [Google Scholar] [PubMed]

30. Redda YT, Kebede E, Cruz C, Gugsa G, Awol N, Mengeste B. Potential antibacterial activity of crude extracts from Aloe vera, Zingiber officinale and Vinca major medicinal plants. Int J Microbiol Res. 2014;5(3):202-207.
31. Jindal V, Kapoor K. Puri C, Goel A, Kaur R, Jaggi D. Healing energy of nature, implicated in periodontal therapy: aloe-vera. A comparative study. Int J Curr Res. 2017;9(12):62395-62398.
32. Murillo G, Vargas MA, Castillo J, Serrano JJ, Ramirez GM, Viales JH, et al. Prevalence and severity of plaque-induced gingivitis in three Latin American cities: Mexico City-Mexico, great metropolitan Area-Costa Rica and Bogota-Colombia. Odovtos-Int J Dent Sc. 2018;20(2):91-102.
33. Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003;31:3-24.

    [Crossref] [Google Scholar] [PubMed]

34. Califano JV. Position paper: Periodontal diseases of children and adolescents. J Periodontol. 2003;74(11):1696-1704.

    [Crossref] [Google Scholar] [PubMed]

35. Tariq M, Iqbal Z, Ali J, Baboota S, Talegaonkar S, Ahmad Z, et al. Treatment modalities and evaluation models for periodontitis. Int J Pharm Investig. 2012;2(3):106.

    [Crossref] [Google Scholar] [PubMed]

36. Vasanthakumari A, Vivek K, Ganesh IJ, Reddy V, Lokesh S. Traditional herbs– An alternative in dentistry: A Review. Glob J Res Anal. 2018;7(8).
37. Davis RH, Leitner MG, Russo JM, Byrne ME. Wound healing. Oral and topical activity of Aloe vera. J Am Podiatr Med Assoc. 1989;79(11):559-62.

    [Crossref] [Google Scholar] [PubMed]

38. Nasiri P, Shafaroudi AM, Moosazadeh M, Poorkazemi D, Sabet JM. The potential of aloe vera as an active ingredient in toothpaste formulations: A narrative review. Jundishapur J Nat Pharm Prod. 2022;17(2).

    [Crossref] [Google Scholar]

39. Li Y, Lee S, Hujoel P, Su M, Zhang W, Kim J, et al. Prevalence and severity of gingivitis in American adults. Am J Dent. 2010;23(1):9.

    [Google Scholar] [PubMed]

40. Idrees MM, Azzeghaiby SN, Hammad MM, Kujan OB. Prevalence and severity of plaque-induced gingivitis in a Saudi adult population. Saudi Med J. 2014;35(11):1373.

    [Google Scholar] [PubMed]

41. Subramaniam P, Dwivedi S, Uma E, Babu KG. Effect of pomegranate and aloe vera extract on streptococcus mutans: An: in vitro: study. Dent. Hypotheses. 2012;3(3):99-105.
42. Reynolds T, Dweck AC. Aloe vera leaf gel: A review update. J Ethnopharmacol. 1999;68(1-3):3-7.

    [Crossref] [Google Scholar] [PubMed]

43. Anushri M, Yashoda R, Puranik MP. Herbs: A good alternatives to current treatments for oral health problems. Dermatitis. 2015;7:9-12.
44. Tanaka M, Misawa E, Yamauchi K, Abe F, Ishizaki C. Effects of plant sterols derived from Aloe vera gel on human dermal fibroblasts in vitro and on skin condition in Japanese women. Clin Cosmet Investig Dermatol. 2015:95-104.

    [Crossref] [Google Scholar] [PubMed]

45. Wynn RL. Aloe vera gel: Update for dentistry. Gen Dent. 2005;53(1):6-9.

    [Google Scholar] [PubMed]

46. Christaki EV, Florou-Paneri PC. Aloe vera: A plant for many uses. J Food Agric Environ. 2010;8(2):245-249.
47. Iglesias MT, De Lorenzo C, Polo MD, Martín-Álvarez PJ, Pueyo E. Usefulness of amino acid composition to discriminate between honeydew and floral honeys. Application to honeys from a small geographic area. J Agric Food Chem. 2004;52(1):84-89.

    [Crossref] [Google Scholar] [PubMed]

48. Qamar Z, Alghonaim MF, Almohana SA, Almohana AA, Zeeshan T. Potential biochemical effects of honey in oral health care: A review. Int Food Res J. 2021;28(1).
49. Taib H, Kamarulzaman N, Min HJ, Berahim Z, Zainuddin SL. Evaluation of the complementary effect of tualang honey to non-surgical periodontal therapy: Clinical application. J Int Dent Med Res. 2018;11(2):650-655.
50. Zhou J, Suo Z, Zhao P, Cheng N, Gao H, Zhao J, et al. Jujube honey from China: Physicochemical characteristics and mineral contents.   J Food Sci. 2013;78(3):387-94.

    [Crossref] [Google Scholar] [PubMed]

51. Roshan AR, Gad HA, El-Ahmady SH, Abou-Shoer MI, Khanbash MS, Al-Azizi MM. Characterization and discrimination of the floral origin of sidr honey by physicochemical data combined with multivariate analysis. Food Anal Methods. 2017;10:137-146.

    [Crossref] [Google Scholar]

52. Petrus K, Schwartz H, Sontag G. Analysis of flavonoids in honey by HPLC coupled with coulometric electrode array detection and electrospray ionization mass spectrometry. Anal Bioanal Chem. 2011;400:2555-2563.

    [Crossref] [Google Scholar] [PubMed]

53. Manyi-Loh CE, Ndip RN, Clarke AM. Volatile compounds in honey: A review on their involvement in aroma, botanical origin determination and potential biomedical activities. Int J Mol Sci. 2011;12(12):9514-9532.

    [Crossref] [Google Scholar] [PubMed]

54. Mohamed HG, Idris SB, Mustafa M, Ahmed MF, Åstrøm AN, Mustafa K, et al. Impact of chronic periodontitis on levels of glucoregulatory biomarkers in gingival crevicular fluid of adults with and without type 2 diabetes. PLoS One. 2015;10(5):127660.

    [Crossref] [Google Scholar] [PubMed]

55. Sundarkar P, Govindwar R, Nyamati SB, Alladwar N, Thombre V, Soni A, et al. Use of Aloe vera in dentistry. J Indian Acad Oral Med Radiol. 2011;23:389-391.
56. Rahmani AH, Aldebasi YH, Srikar S, Khan AA, Aly SM. Aloe vera: Potential candidate in health management via modulation of biological activities. Pharmacogn Rev. 2015;9(18):120.

    [Crossref] [Google Scholar] [PubMed]

57. Al-Yahya M, Mothana R, Al-Said M, Al-Dosari M, Al-Musayeib N, Al-Sohaibani M, et al. Attenuation of CCl 4-induced oxidative stress and hepatonephrotoxicity by Saudi Sidr honey in rats. Evid Based Complement Alternat Med. 2013;2013.

    [Crossref] [Google Scholar] [PubMed]

58. Merckoll P, Jonassen TØ, Vad ME, Jeansson SL, Melby KK. Bacteria, biofilm and honey: A study of the effects of honey on ‘planktonic’and biofilm-embedded chronic wound bacteria. Scand J Infect Dis. 2009;41(5):341-347.

    [Crossref] [Google Scholar] [PubMed]

59. Reuter J, Merfort I, Schempp CM. Botanicals in dermatology: an evidence-based review. Am J Clin Dermatol. 2010;11:247-267.

    [Crossref] [Google Scholar] [PubMed]

60. Khalil MI, Tanvir EM, Afroz R, Sulaiman SA, Gan SH. Cardioprotective effects of tualang honey: Amelioration of cholesterol and cardiac enzymes levels. Biomed Res Int. 2015;2015.

    [Crossref] [Google Scholar] [PubMed]

61. Westfelt E. Rationale of mechanical plaque control. J Clin Periodontol. 1996;23(3):263-267.

    [Crossref] [Google Scholar] [PubMed]

62. Suomi JD. Prevention and control of periodontal disease. J Am Dent Assoc. 1971;83(6):1271-1287.

    [Crossref] [Google Scholar] [PubMed]

63. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology. Elsevier health Sciences. 2011.